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a road map to managing dental trauma!
with predictable outcomes
h. ryan kazemi, dmd!
oral and maxillofacial surgeon!
bethesda, MD
to view this presentation
facialart.com/presentations
academyforsportsdentistry.org
join
common causes
falls
playground accident
abuse
bicycle
mva
assaults
altercations
athletic injuries
predisposing factors
abnormal occlusions
overjet > 4 mm
labially inclined incisors
lip in competence
short upper lip
mouth breathing
mechanism of injury
timing
bleeding?
loc?
history
account for all teeth
tissue
teeth position
lacerations
examination
teeth!
mobilities
extent of!
injury
alveolar bone
embedded FB
submandibular!
duct
parotid duct
examination
FOM
teeth!
fractures
tongue
nerves
vessels
facial!
wounds
facial!
fractures
vitality test!
- short term!
- long term
examination- teeth
percussion!
- pain ! —> injury to periodontal ligament!
- sound —> dull (subluxated) or hard metallic (locked)
teeth!
color
day 0 day 28 2 months 3 months
0 29.4% 82.35% 94.11%
positive responsiveness in pulp tests
panorex
radiographs
periapical
CBCT root fractures
degree of extrusion or intrusion
periodontal disease
root development
size of pulp chamber & canal
jaw fractures
tooth fragments
caries
oral!
surgeon
team communication
endodontist
restorative!
dentist
hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
crown infraction!
uncomplicated crown fracture!
complicated crown fracture!
uncomplicated crown-root fracture!
complicated crown-root fracture!
root fracture
hard dental
tissue & pulp
impact to only enamel!
transillumination for dx!
upper incisor labial aspect!
—> no treatment!
vitality check & f/u!
if non vital at time of exam,
observe
crown infraction
hard dental
tissue & pulp
enameloplasty!
composite restoration
crown fracture
uncomplicated- enamel only
hard dental
tissue & pulp
seal dentin tubules!
promote secondary dentin
deposition!
calcium hydroxide liner
over dentin and composite
restoration!
monitor vitality
crown fracture
uncomplicated- enamel & dentin
glass ionomer
CaOH2 solubility in water —> dissolution
hard dental
tissue & pulp
enamel & dentin with
exposure of pulp!
!
treatment options:!
pulp capping!
partial pulpotomy!
endodontic treatment
crown fracture
complicated- enamel &
dentin with exposure of pulp
hard dental
tissue & pulp
tooth is sound & small exposure!
!
!
pulp capping!
(CH or MTA)
crown fracture
complicated- enamel &
dentin with exposure of pulp
MTA- mineral trioxide aggregate!
•forms CH that releases ca ions for cell
attachment and proliferation!
•creates an antibacterial environment
with its alkaline PH!
•modulated cytokine production!
•encourages differentiation and migration
of hard tissue producing cells!
•forms hydroxyapatite on MTA surface
and provides a biological seal
Pitt-Ford and Patel: Most pulps
capped with MTA were free of
inflammation and showed
calcified bridge after 5 months
hard dental
tissue & pulp
!
immature teeth with open apex!
!
!
cervical pulpotomy!
(MTA / CH)
crown fracture
complicated- enamel &
dentin with exposure of pulp
2-4 mm
most require pulpectomy after root development is completed
pulpotomy & capping
MTA or Biodentine courtesy: Dr. Pirooz Zia
Biodentine™: a dentin substitute indicated for use in:!
!
crown for temporary enamel restorations!
permanent dentin restorations!
deep or large carious lesions!
deep cervical or radicular lesions!
pulp capping or pulpotomy!
used in the root for root and furcation perforations!
internal and external resorptions!
apexification!
retrograde surgical filling.
biodentine!
bioactive dentin substitute
sets in 10 - 12 minutes!
!
natural micro mechanical anchorage
for excellent sealing properties
without surface preparation.!
!
similar mechanical properties and
mechanical behavior as human
dentin.!
!
3.5mm aluminum radiopacity for
easy short and long term follow-up.
biodentine!
bioactive dentin substitute
hard dental
tissue & pulp
!
mature teeth with closed apex!
!
!
pulpectomy &
endodontic tx
crown fracture
complicated- enamel &
dentin with exposure of pulp
hard dental
tissue & pulp
treatment depending on
amount of root remaining!
primary teeth —> extract!
permanent teeth —>!
> extract: too apical / vertical!
> rct / ortho eruption!
> rct and submerge root!
> extraction / site graft!
> extraction / immed. implant
crown-root fractures
uncomplicated (no pulp exposure)
uncomplicated!
crown fracture
uncomplicated!
crown root fracture
restored extracted
extraction with no
grafting per patient
3 months
loss of
buccal plate
1!!
graft
6 months
2!!
implant
3!!
provisional!
for 3 m
4!!
final
hard dental
tissue & pulp crown-root fractures
complicated (pulp exposure)
treatment depending on
amount of root remaining!
primary teeth —> extract!
permanent teeth —>!
> extract: too apical / vertical!
> rct / ortho eruption!
> rct and submerge root!
> extraction / site graft!
> extraction / immed. implant
no bone
no implant
hard dental
tissue & pulp
75% involve centrals!
40% with alveolar bone fx!
primary teeth —> if no
mobility, may preserve and
allow normal exfoliation. If
mobile, then extract
root fractures
hard dental
tissue & pulp
permanent teeth!
apical third level!
!
no mobility- prognosis
good with minimal
treatment.!
coronal aspect may remain
vital and no endo treatment
may be necessary.
root fractures
hard dental
tissue & pulp root fractures
permanent teeth!
mid-root level!
!
may have fair prognosis!
needs splinting: 2-3 month!
check vitality continually!
resorption in 60% within 1y!
!
>> immediate implant / graft!
>> site graft / delayed implant
hard dental
tissue & pulp root fractures
permanent teeth!
high-root level!
!
poor prognosis!
atraumatic extraction!
!
>> immediate implant / graft!
>> site graft / delayed implant
healing by ‘calcific callus’
courtesy: Dr. Pirooz Zia
is buccal!
bone intact?
buccal
bone
intact
tooth fracture!
(adult)
above bone at bone below bone
no pulp
exposure
pulp
exposure
minor!
fracture
sig!
fracture
buccal
bone
no buccal
bone
restore pulpectomy
restore
crown
length or
ortho
eruption
treat same as
below bone
fracture
extract!
graft
implant
extract!
implant!
graft
hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
concussion!
subluxation (loosening)!
intrusive luxation (central dislocation)!
extrusive luxation (partial avulsion)!
lateral luxation!
retained root fracture!
exarticulation (complete avulsion)
periodontal!
tissue
tooth is tender to touch!
no mobility!
percussion sensitive!
no treatment!
check vitality later as
necrosis can develop in
several weeks to months
concussion
periodontal!
tissue
bleeding is common!
percussion sensitive!
positive mobility!
treatment: non-rigid splint
for 7-10 days!
monitor for pulp
complications
subluxation
periodontal!
tissue
compression into socket!
impaction to complete
disappearance in alveolus!
significant damage to pdl!
high incidence of external
resorption, pulp necrosis,
marginal bone loss!
percussion- dull metallic
intrusive luxation
periodontal!
tissue
treatment options!
!
re-erupt if immature tooth!
immediate repositioning
(high resorption / bone loss)!
low-force ortho reposition!
extraction!
primary teeth —> extract
intrusive luxation
periodontal!
tissue
apex displaced out of
socket with NV rupture!
pdl space is widened!
dull percussion sound!
primary tooth —> extract
extrusive luxation
periodontal!
tissue
treatment- permanent teeth!
manipulate into socket!
nonrigid splint 1-2 weeks!
!
>> within few hours of injury!
>> after 33 hours- increased
rate of pulp necrosis
extrusive luxation
periodontal!
tissue
often with
bone fracture!
reposition &
compress!
splint 2-8
weeks!
endo tx
lateral luxation
incomplete root
formation!
!
endo treatment may
not be necessary
endodontic consult
periodontal!
tissue
fracture of root at cervical
or deeper!
treatments:!
>> extract / implant / graft!
>> extract / graft!
>> endo / submerge!
>> endo / ortho eruption
retained root fracture
periodontal!
tissue
extract, implant, graft!
if!
buccal bone intact!
gingival margin is ideal!
can achieve primary
implant stability!
tissue not traumatized /
infected
retained root fracture
periodontal!
tissue
extract & graft!
if!
buccal bone is not intact!
bone loss has occurred!
primary implant stability
can not be achieved!
tissue is traumatized
retained root fracture
periodontal!
tissue
rct & submerge!
(preserve tissue)!
if!
no bone fracture!
patient growth incomplete!
adult patient with soft
tissue loss (goal is to
regenerate soft tissue)
retained root fracture
periodontal!
tissue
rct & ortho eruption!
(to augment tissue)!
if !
no bone fracture!
soft tissue is apical to
adjacent gingival margin!
vertical bone loss (good
bone level on adjacent
tooth)
retained root fracture
best tissue preservation!
!
immediate implant!
bone graft in gap!
immediate provisional
to support soft tissue
periodontal!
tissue
15% of permanent teeth!
7-13% of primary teeth!
maxillary incisors!
most common age 7-10!
treatment goal: maintain
vitality of cells (pulp & pdl)
avulsion (exarticulation)
periodontal!
tissue
time
avulsion (exarticulation)
within!
30 minutes
periodontal!
tissue
other factors for success!
!
width & length of root canal!
stage of root development!
type of storage medium!
degree of oral trauma
avulsion (exarticulation)
periodontal!
tissue
treatment options!
!
re-implantation!
immediate implant / graft!
site graft / delayed implant
avulsion (exarticulation)
periodontal!
tissue
Andreasen & Hjorting-Hansen!
!
after 2 years or more, 90%
of teeth re-implanted within
30 minutes exhibit no
discernible resorption of
roots!
95% resorption if > 2 hours
avulsion (exarticulation)
re-implantation
resorption in avulsion cases
courtesy: Dr. Pirooz Zia
periodontal!
tissue
early re-implantation is key!
instructions if at site of injury!
1. inspect tooth for debris!
2. hold only by crown!
3. cleanse with milk or saliva!
4. put tooth into socket!
5. hold with light pressure!
6. come to office
avulsion (exarticulation)
periodontal!
tissue
storage!
!
buccal vestibule!
under tongue!
milk!
hanks balanced salt
solution!
NO TAP WATER
avulsion (exarticulation)
periodontal!
tissue avulsion (exarticulation)
medium ph osmolarity
saline 7.0 295
tap water 7.5 12
salive 6.3 110-120
viaspan 7.4 320
gatorade 3.0 280-360
milk 6.75 275
coconut water 6.2 288
blood plasma 7.2-7.4 290
hank’s bss 7.0 270-290
hypotonic
periodontal!
tissue
assessment!
!
history!
type of injury!
how long ago?!
‘dry time’!
exam site!
accountability of teeth!
type of storage medium
avulsion (exarticulation)
re-implantation
periodontal!
tissue
primary teeth!
!
do not!
re-implant
avulsion (exarticulation)
re-implantation
periodontal!
tissue
conditions before!
re-implantation!
!
tooth without perio disease!
socket intact!
no ortho issues- crowding!
less than 30 minutes!
stage of root development
(incomplete >> within 2 h)
avulsion (exarticulation)
re-implantation
periodontal!
tissue
treatment- closed apex!
(dry time < 30 min; tooth in medium 20 min to 6 h)!
!
irrigate tooth if with debris!
clean coagulum with saline!
re-implant and press!
splint while patient in occlusion!
nonrigid splint for 1-2 wk!
if bone fx —> splint 3-4 wk!
suture lacerations
avulsion (exarticulation)
re-implantation
periodontal!
tissue
treatment- closed apex!
(dry time > 60 min)!
!
irrigate tooth if with debris!
clean coagulum with saline!
immerse tooth in sodium fluoride
solution- 5 minutes!
re-implant and press!
keep patient in occlusion!
nonrigid splint for 4-6 wks
avulsion (exarticulation)
re-implantation
periodontal!
tissue
Post treatment- closed apex!
!
doxycycline or penicillin vk for 7 days!
chlorhexidine rinse for 1 week!
assess tetanus vaccination!
soft diet 2 weeks!
initiate pulpectomy within 7-14 days
avulsion (exarticulation)
re-implantation
periodontal!
tissue
treatment- open apex!
(dry time < 30 min; tooth in medium 20 min to 6 h)!
!
irrigate tooth if with debris!
tooth in doxycycline (100 mg / 20 cc
saline) for 5 minutes!
clean coagulum with saline!
re-implant and press!
keep patient in occlusion!
nonrigid splint for 1-2 wk
avulsion (exarticulation)
re-implantation
periodontal!
tissue
treatment- open apex!
(dry time > 60 min)!
!
reimplantation usually not indicated (per
american association of endodontics)!
may follow same protocol as closed apex
(McIntyre, Lee, Trope- permanent tooth
replantation following avulsion- pediatric dent
31:137, 2009)
avulsion (exarticulation)
re-implantation
periodontal!
tissue
post treatment- open apex!
!
doxycycline or penicillin vk for 7 days!
chlorhexidine rinse for 1 week!
assess tetanus vaccination!
soft diet 2 weeks!
monitor every 4 weeks + pulp test + X-rays!
apexogenesis over next 12-18 months?
avulsion (exarticulation)
re-implantation
periodontal!
tissue
follow-up procedures
avulsion (exarticulation)
re-implantation
time closed apex open apex
1-2 weeks initiate endo treatment endo or monitor for vascularity
2-3 weeks clinical & x-ray eval clinical & x-ray eval
3-4 weeks clinical & x-ray eval clinical & x-ray eval
6-8 weeks clinical & x-ray eval clinical & x-ray eval
6 months clinical & x-ray eval clinical & x-ray eval
1 year clinical & x-ray eval clinical & x-ray eval
yearly for 5 years clinical & x-ray eval clinical & x-ray eval
hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
comminution of the alveolar socket!
fracture of the alveolar socket wall!
fracture of the alveolar process!
fractures of the mandible or maxilla
supporting!
bone
reduce with digital
manipulation!
if tooth can not be
preserved, extract and
graft site to preserve tissue
comminution- alveolar bone
supporting!
bone
reduce!
rigid splint for 4 weeks!
primary teeth- may not
need any treatment
fracture of socket wall
supporting!
bone
closed reduction!
open reduction if segment
is notably displaced!
stabilization for 4 weeks!
check teeth vitality and
monitor
fracture- alveolar process
hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
laceration of gingiva or oral mucosa!
contusion of gingiva or oral mucosa!
abrasion of gingiva or oral mucosa
gingiva or
oral mucosa
management!
!
debridement!
irrigate NS!
re-approximate!
primary closure
lacerations
splinting!
techniques
splinting- acid etch resin splint
light cured preferred to allow time!
bridge: resin or wire (28g)
splinting- semirigid splint
resin with waxed dental floss, suture,
flexible braided ortho wire or
monofilament nylon line!
kevlar!
fiber splints (fiber force)- use with
protemp material for more movement!
flexible wire composite splints!
titanium splints
splinting- semirigid splint
fiber splints
splinting- semirigid splint
hard dental
tissue & pulp
periodontal!
tissue
supporting!
bone
gingiva or
oral mucosa
multi-system injuries
• tooth avulsion!
• fracture alveolar bone!
• extrusive luxation!
• lacerations!
• crown fractures
surgical order!
!
inside-out!
downward-up
1. extract fractured teeth!
2. debridement of avulsion site!
3. reduce dentoalveolar fracture segment!
4. splint teeth / alveolar segment!
5. graft extraction / avulsion site!
6. closure of lacerations
thank you
facialart.com/presentations

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